Late functional adaptation after colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis (IPAA) is currently an alternative to proctocolectomy and ileostomy for patients with ulcerative colitis or familial polyposis. Some studies have suggested significant anal sphincter damage after mucosal proctectomy. Our aim was to assess prospectively late sphincter function after IPAA. In 250 patients, anorectal pressures were assessed with a pneumohydraulic perfused catheter manometry system. Each patient underwent colectomy, mucosal proctectomy, ileoanal anastomosis of a 15 cm ileal J-pouch, and loop ileostomy. Eight weeks after IPAA, anal manometry was repeated, and the ileostomy was closed. Manometry was repeated at yearly intervals. A decline in resting tone of the anal sphincter occurred early after IPAA with a gradual recovery toward control. External sphincter squeeze after pressures were not affected by IPAA and steadily increased to 8 years after operation. During this time, a progressive increase in J-pouch capacity was noted, and 24-hour stool frequency declined from 7.9 +/- 0.3 stools to 6.5 +/- 0.3 stools (p less than 0.05). We conclude that mucosal proctectomy results in internal anal sphincter trauma but is associated with long-term sphincter recovery, coupled with a significant improvement in external sphincter capacity, ileal pouch volume, and stool frequency.     

Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa.

OBJECTIVE: The purpose of the study is to compare the results of ileal pouch-anal anastomosis (IPAA) in patients in whom the anal mucosa is excised by handsewn techniques to those in whom the mucosa is preserved using stapling techniques. SUMMARY BACKGROUND DATA: Ileal pouch-anal anastomosis is the operation of choice for patients with chronic ulcerative colitis requiring proctocolectomy. Controversy exists over whether preserving the transitional mucosa of the anal canal improves outcomes. METHODS: Forty-one patients (23 men, 18 women) were randomized to either endorectal mucosectomy and handsewn IPAA or to double-stapled IPAA, which spared the anal transition zone. All patients were diverted for 2 to 3 months. Nine patients were excluded. Preoperative functional status was assessed by questionnaire and anal manometry. Twenty-four patients underwent more extensive physiologic evaluation, including scintigraphic anopouch angle studies and pudendel never terminal motor latency a mean of 6 months after surgery. Quality of life similarly was estimated before surgery and after surgery. Univariate analysis using Wilcoxon test was used to assess differences between groups. RESULTS: The two groups were identical demographically. Overall outcomes in both groups were good. Thirty-three percent of patients who underwent the handsewn technique and 35% of patients who underwent the double-stapled technique experienced a postoperative complication. Resting anal canal pressures were higher in the patients who underwent the stapled technique, but other physiologic parameters were similar between groups. Night-time fecal incontinence occurred less frequently in the stapled group but not significantly. The number of stools per 24 hours decreased from preoperative values in both groups. After IPAA, quality of life improved promptly in both groups. CONCLUSIONS: Stapled IPAA, which preserves the mucosa of the anal transition zone, confers no apparent early advantage in terms of decreased stool frequency or fewer episodes of fecal incontinence compared to handsewn IPAA, which excises the mucosa. Higher resting pressures in the stapled group coupled with a trend toward less night-time incontinence, however, may portend better function in the stapled group over time. Both operations are safe and result in rapid and profound improvement in quality of life.     

Terminal motor latency in the pudendal nerves after colectomy with mucosal proctectomy and ileal J pouch-anal anastomosis for ulcerative colitis

Pudendal nerve terminal motor latencies (PNTML) were measured in eight patients with ulcerative colitis who underwent colectomy with mucosal proctectomy and ileal J pouch-anal anastomosis, using a new digitally directed transrectal stimulation and recording technique, and the results were compared with data obtained from 15 control subjects. The conduction delay of PNTML in the patients with some degree of fecal incontinence was the longest, followed by those without any incontinence, and then the control subjects. These findings support the hypothesis that fecal incontinence after this procedure may be partially caused by damage to the pudendal nerve.     

Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy.

Forty-nine patients with chronic ulcerative colitis refractory to medical therapy and four with multiple polyposis have undergone total colectomy, mucosal protectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during the past 12 years (mean age, 19.4 years). Thirty-eight patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pullthrough operation. The anastomosis extended over a 20-30 cm distance and the lower end was placed within 6-8 cm of the ileonanal anastomosis. Transient reservoir inflammation, which occurred in half of the patients, was reduced by the use of oral metranidazole and was rarely found 6 months after operation. No patients died during the early or late post-operative periods. Cuff abscess in two patients and obstruction of the ileal reservoir outlet have required takedown of the reservoir (two patients) or temporary ileostomy (three patients). Of the 38 patients who have undergone lateral ileal reservoir construction, 33 have achieved a good to excellent result with complete continence and an average of five stools per 24 hours after 6 months. At least 12 patients now participate in competitive athletics; normal sexual activity has been achieved in all but one patient. Seven patients await construction of the reservoir. Although a technically difficult operation, the long-term results (mean, 19.4 months) indicate that the pullthrough operation is a good alternative to standard proctocolectomy.     

Complications associated with ileal pouch-anal anastomosis.

Seventy-three patients underwent total colectomy, rectal mucosectomy, creation of J or S ileal reservoir, and ileal pouch-anal anastomosis from 1982 to 1989. Mean follow-up was 38 months, with a minimum of 3 months in 15 patients being followed long-term at another institution. Forty-eight (66%) patients had histologically proven ulcerative colitis and 25 (34%) patients had familial polyposis. Thirty-eight J reservoirs and 35 S reservoirs were constructed. There were no perioperative deaths. The failure rate (loss of pouch) was 3%. Thirty-six complications in 34 (47%) patients were reported, 14 (19%) patients required surgery. Bowel obstruction was the most common postoperative complication (16%), followed by pouchitis (15%), and cuff infection (5%). Seventy-eight percent of the complications were associated with the J pouch. Average stool frequency at 1 year was 4 per 24-hour period. Other complications included postoperative pneumonia (1), peroneal nerve palsy (1), and temporary sexual dysfunction (1). Seven of 15 complications requiring surgical intervention occurred in the first 2 years of the study period, illustrating the learning curve associated with the procedure. Blood loss, transfusion requirements, and length of operation were not associated with higher complication rates. Use of the J pouch and experience of the individual surgeon affected morbidity.     

The ParkS S ileal pouch and anal anastomosis after colectomy and mucosal proctectomy

Attention to detail is crucial to the success of the operation described. Surgeons contemplating performing it should first be experts in pelvic surgery and are advised to personally observe and participate in the procedure performed by surgeons currently experienced in this technique.     

Total laparoscopic ileal pouch-anal anastomosis: prospective series of 82 patients

Background  Ileal pouch-anal anastomosis (IPAA) is the recommended procedure for ulcerative colitis and profuse familial adenomatous polyposis. The aims of this study were to report a consecutive series of 82 unselected patients who undergone a total laparoscopic IPAA with a special focus on the postoperative morbidity and 1-year functional results. Methods  Between 2002 and 2008, 82 consecutive patients undergoing IPAA under a total laparoscopic approach were enrolled. Patient data, surgical procedure, and 1-year functional outcome were analyzed. Results  Among the 82 patients, 44 (54%) had a former subtotal colectomy (STC) before IPAA. No patient died postoperatively. Conversion rate was 11%. Overall morbidity was 32%. Symptomatic anastomotic fistulas were observed in nine patients (10%). Reoperation was needed in 5/82 (6%) of the patients. One-year functional results were 4.7 ± 1.9 during the day and 1 ± 1.2 during the night. Operating time decreased significantly after the first 40 laparoscopic IPAA (p = 0.0183). No difference was observed in the morbidity and functional results between patients operated for IPAA after a former colectomy or during a restorative proctocolectomy. Conclusions  This study suggested the feasibility and safety of the total laparoscopic approach IPAA. Total laparoscopic approach could become the best approach for IPAA. Prior colectomy does not modify the result of this demanding surgical procedure.     

Functional outcome of stapled ileal pouch-anal canal anastomosis versus handsewn pouch-anal anastomosis

This study was conducted to determine whether stapled ileal pouch-anal canal anastomosis (IACA) preserving the anal transitional zone (ATZ) or hand-sewn ileal pouch-anal anastomosis with mucosectomy (IPAA) is more beneficial in achieving disease eradication and better postoperative function. IACA was performed in 10 patients with ulcerative colitis (UC) and 10 patients with familial adenomatous polyposis (FAP), 15 of whom were examined proctoscopically. IPAA was performed in 4 patients with UC and 8 patients with FAP. The mean maximum resting pressure (MRP) was 55 mmHg in the IACA group and 34 mmHg in the IPAA group (P < 0.01). The anorectal inhibitory reflex was positive in 18 patients (90%) from the IACA group and 5 (42%) from the IPAA group (P < 0.05). The pre- and postoperative MRPs were 61 mmHg and 55 mmHg, respectively, in the IACA group vs 63 mmHg and 34 mmHg, respectively, in the IPAA group (P < 0.01). Whereas 16 (80%) of the 20 IACA patients could discriminate feces from gas, only 4 (33%) of the 12 IPAA patients could (P < 0.05). The mean observation period was 2.3 years, the mean length of the columnar cuff was 2.8 cm, and no case of dysplasia or adenoma was seen. Postoperative function is more favorable following IACA than following IPAA, both physiologically and symptomatically. However, long-term surveillance of the residual mucosa is necessary before making a final recommendation. Received: April 20, 1999 / Accepted: January 7, 2000     

Small intestinal obstruction complicating ileal pouch-anal anastomosis.

Small bowel obstruction remains the most common complication after proctocolectomy with ileal pouch-anal anastomosis. Of 626 patients who underwent this operation between January 1981 and October 1986 for ulcerative colitis (544 patients), familial adenomatous polyposis (72 patients), or indeterminate colitis (ten patients), 17% developed small bowel obstruction, 7.5% of whom required surgical intervention. The obstruction occurred either before or after closure of the temporary ileostomy. Patients who had a temporary Brooke ileostomy were more likely to develop obstruction (four of 32 patients, 12.5%) than those who had a loop ileostomy (25 of 564 patients, 4.6%) (p = 0.07). Also, patients who had had previous operations were at greater risk of obstruction (8.5%) than those who had not (2.2%) (p less than 0.04).     

Anal and neorectal function after ileal pouch-anal anastomosis.

Bowel function varies markedly among patients with colectomy and ileal pouch-anal anastomosis. Little is known of the mechanisms controlling fecal continence and frequency of defecation after operation. The aim of this study was to determine which features of the anal sphincter and neorectum accounted for the variation in clinical outcome. Twenty patients were studied 4 to 35 months after operation and compared to 12 healthy volunteers. Despite several patients exhibiting impaired fecal continence, anal sphincteric length and pressures and ileal pouch capacity and distensibility were similar in patients and controls. Patients with poor results, however, had rapid filling of their ileal pouch, which resulted in early onset of high amplitude propulsive pressure waves in the pouch. As these waves became more frequent, defecation resulted. Patients with poor results also were not able to empty adequately their pouch. The poorer the completeness of evacuation, the more frequent the defecation (r = 0.62, p less than 0.01). The authors conclude that rapid pouch filling and impaired pouch evacuation can lead to increased stool frequency in patients after ileal pouch-anal anastomosis.     

Stricture and pouchitis after ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis is a surgical procedure used for the treatment of people with chronic ulcerative colitis and familial adenomatous polyposis. The surgery is intended to preserve anal sphincter function, but it carries a risk for certain complications, including pouchitis and anastomotic stricture. The purpose of this article is to review the clinical manifestations, causes, and treatment of anastomotic stricture and pouchitis after ileal pouch-anal anastomosis.     

Transsacral fistula of an ileal pouch-anal anastomosis

For patients with ulcerative colitis and familial adenomatous polyposis the restorative proctocolectomy with ileo-anal-pouch anastomosis is the surgical treatment of choice. Leakage from the ileo-pouch anastomosis is the surgical treatment of choice. Leakage from the ileo-pouch-anastomosis can be a difficult to manage complication, which in some cases resists all attempts at local repair. A surprising complication of a 28 years old woman patient with an ileo-anal-pouch anastomotic fistula is presented. The fistula developed the 4th day postoperatively. Local irrigation and transanal drainage seemed to have a good result, the patient being examined after two weeks. During an apparently better evolution, after one month, the patient developed a transsacral fistula with local abscess and osteolysis. The ileo-anal-pouch anastomosis was converted to a less comfortable conventional ileostomy, but with good local and general final result.     

回肠贮袋肛门吻合术的现状与争议

自1978年Parks等[1]首次报道以来,全结肠切除、部分直肠切除、直肠黏膜剥除、回肠贮袋肛门吻合术(ileal pouch-anal anastomosis,IPAA)逐渐成为治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)和溃疡性结肠炎(ulcerative colitis,UC)的标准术式.     

Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in the ileal pouch operation

Ten patients have undergone abdominal proctocolectomy with the formation of an ileal reservoir anastomosed onto the anal canal using a stapling device. This technique avoids stripping of the rectal mucosa from the muscle tube (mucosal proctectomy) which is time consuming and often difficult. One patient is awaiting closure of her ileostomy. The remaining seven are continent and are passing between one and six motions a day.     

Determinants of stool frequency after ileal pouch-anal anastomosis

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.     

Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch-anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 +/- 2 months (mean +/- s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch-anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.     

Motility of the small intestine after proctocolectomy and ileal pouch-anal anastomosis.

Though the mechanisms of continence after proctocolectomy and ileal pouch-anal anastomosis have been studied, functions of the small intestine have received little attention. However, frequent stools and urgency plague some patients who are otherwise quite continent. Motility of the jejunum and ileum was assessed in eight patients with ulcerative colitis who were studied 4 to 24 months after proctocolectomy and ileal pouch-anal anastomosis; these findings were compared to those in six healthy volunteers. Continuous manometric recordings from the small bowel were obtained in both groups for 16 to 23 hours of fasting; postprandial recordings were made for 6 hours following a mixed meal (800 kcal, 20% protein, 40% fat, 40% carbohydrate) in the ileoanal patients. The duration, velocity of propagation, and periodicity of the migrating motor complex did not differ between the groups (P greater than 0.05). Discrete bursts of clustered contractions were recorded from all of the controls and in five of eight patients. Likewise, we recorded from all controls and five of eight patients large amplitude, prolonged waves of pressure which propagated distally. However, in controls these large amplitude waves were confined to the terminal ileum, but in patients these were detected in the jejunoileum, up to 125 cm proximal to the ileal pouch. We conclude that jejunoileal motility is not greatly altered by proctocolectomy with ileal pouch-anal anastomosis. However, the appearance of the large amplitude, rapidly propagating waves in the proximal jejunoileum after operation may be a response to increased storage within and distention of the distal bowel.     

Gangrenous pyoderma and enterocutaneous fistulas after ileal pouch-anal anastomosis

We describe the medical-surgical management of a patient with a complex inflammatory bowel disease who developed 2 acute episodes of pyoderma gangrenosum and enterocutaneous fistulas after ileal pouch-anal anastomosis for ulcerative colitis. The rarity of this postsurgical complication is emphasized. A good response to topical tacrolimus was achieved in cutaneous wounds. A less favorable response to infliximab was achieved in the abdominal fistulas, requiring surgical excision of the pouch.     

Physiologic determinants of nocturnal incontinence after ileal pouch-anal anastomosis

The goals of the ileal pouch-anal anastomosis (IPAA) operation are the construction of a fecal reservoir and the preservation of anal function, without compromising continence. Some of the patients are incontinent at night. The aim of our study was to identify the mechanisms responsible for nocturnal incontinence. We analyzed patients undergoing IPAA for ulcerative colitis, who underwent anorectal tests between 1993 and 1995. All patients were subjected to pull-through manometry and pelvic floor function studies, and 33 patients underwent overnight ambulatory manometry. Among 44 patients (27 men and 17 women), 22 had complete continence, whereas 22 had nocturnal incontinence. Mean age was 40±1 years. There were no differences with regard to sex, age, stool consistency, and ability to differentiate gas from stool between groups; only stool frequency was lower in the continent group (median [range] 6 [3 to 10] vs. 8 [5 to 25] stools/24 hours;P=0.011). Resting and squeezing anal canal pressure did not differ (P=0.42 andP=0.73, respectively). Resting, squeezing, and defecating anorectal angle, percentage of pouch evacuation, and perineal descent, all measured scintigraphically, did not differ between groups (allP>0.05). Ambulatory manometry showed that the mean anal canal pressure was higher in continent patients compared to incontinent patients, both during awake (88±11 vs. 62±8;P=0.032) and sleep (81±14 vs. 49±9;P=0.029) periods. The motility index was similar (awake,P=0.88; sleep,P=0.95), as was the number of episodes where the pouch pressure was greater than the anal canal pressure (P=0.28). In otherwise continent patients after IPAA, the combination of high stool frequency and low basal anal canal pressure may be related to nocturanal incontinence. Moreover, standard anorectal physiology tests cannot identify these subtle differences. Supported in part by the Crohn's and Colitis Foundation of America, Inc. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.